Secondhand Smoke Jeopardizes Worker Health: The Need for Smoke-free Laws

July 9, 2024

More than 40 years after former U.S. Surgeon General Jesse Steinfeld first exposed the potential health risks of secondhand smoke (SHS) in 1971,[i] and nearly 30 years after a subsequent Surgeon General’s report stated that SHS causes lung cancer and other diseases,[ii] all U.S. workers still do not have the right to breathe smoke-free air. In the late 1980s, 91.7 percent of Americans had an indicator of SHS exposure in their bloodstream[iii] and, at that time, only 3 percent of workers nationally reported a “no smoking” policy at their place of employment.[iv] Soon thereafter, laws prohibiting smoking in workplaces and other public venues were enacted at the local, state, and national levels to minimize the impact of SHS. Two Surgeon General Reports have concluded unequivocally that there is no safe level of exposure to SHS.[v],[vi]

All U.S. workers still do not have the right to breathe smoke-free air.


Today, smoke-free policies have effectively reduced the number of people exposed to SHS in the workplace.[vii],[viii],[ix],[x] The proportion of people who do not smoke with detectable levels of a SHS indicator has dropped from 87.5 percent in 1988  to 20.7 percent in 2018.[xi],[xii] This level of exposure is still too high, and unfortunately, not all workers have the same level of protections. Currently, over 77 percent of the U.S. population is covered by 100 percent smoke-free state or local workplace laws, 78 percent is covered by 100 percent smoke-free restaurant laws, and 66 percent is covered by 100 percent smoke-free bar laws.[xiii] However, only 62 percent of the population is covered by 100 percent smoke-free laws covering all three of these types of venues.[xiv]


Hospitality Workers are at Higher Risk for Secondhand Smoke Exposure

The workplace is a major source of SHS exposure for adults which has been linked to an increased risk of heart disease and lung cancer among nonsmoking adults.[xv] Blue collar and service workers are more likely than white collar workers to be exposed to SHS at the workplace[xvi] and are less likely to be covered by smoke-free policies.[xvii],[xviii]


  • According to one study, prior to the implementation of a smoke-free law, employees working full-time in restaurants or bars that allowed indoor smoking were exposed to levels of air pollution 4.4 times higher than safety levels established by the U.S. Environmental Protection Agency (EPA) because of their occupational exposure to secondhand smoke.[xix]


Bartenders, servers, and casino workers are particularly unlikely to be protected by smoke-free policies and more likely to breathe SHS even when smoke-free policies are in effect for other types of workplaces.[xx],[xxi]  Without smoke-free laws, bars and lounges have among the highest concentrations of SHS of all public spaces – exposing bartenders to even greater levels of SHS than restaurant workers.[xxii]


  • When there are not smoke-free policies in effect, levels of SHS in bars are 3.9 to 6.1 times higher than levels measured at office worksites and up to 4.5 times higher than levels in homes with one or more people who smoke.[xxiii] Bartenders are more likely than many other workers to report eye, nose, or throat irritation or symptoms.[xxiv]
  • A study examining the effects of SHS exposure in San Francisco, CA restaurants and bars before the state’s smoke-free law took effect found that 74 percent of bartenders surveyed had respiratory symptoms (e.g., wheezing, cough, etc.), and 77 percent had sensory irritation symptoms (e.g. red, teary, or irritated eyes, runny nose, sneezing, sore or scratchy throat, etc.).[xxv]
  • Research has found that individuals who do not smoke and are exposed to high levels of SHS are more likely to experience severe headaches or migraines.[xxvi]


Research on the health effects of SHS found exposure to SHS increases the risk of ischemic heart disease, stroke, type 2 diabetes, and lung cancer.xxvii

Casino Workers are Exposed to High Levels of SHS in the Workplace and are at Higher Risk for Developing SHS-related Illnesses

  • A study found the amount of SHS was approximately 12 times greater inside casinos that allowed smoking than outside.[xxvii] [xxviii]
  • A study comparing SHS in 66 U.S. casinos where smoking is allowed with three non-smoking casinos found that the smoke-free casinos had lower levels of SHS.[xxix] In about half of the smoking casinos, the SHS levels exceeded a level known to increase cardiovascular risk in people who do not smoke after less than 2 hours of exposure, posing acute health risks for patrons and workers. In casinos with a non-smoking section, the ventilation systems and separation were unable to remove SHS while smoke-free casinos reduced fine particles from SHS to the same low levels found outdoors.[xxx]
  • Recent studies have shown that unhealthy levels of indoor air pollution were more than five times higher in casinos that permitted smoking compared to smoke-free casinos. [xxxi] Long-term exposure to fine particle air pollution has been associated with cardiovascular and respiratory diseases, lung cancer, and even death.[xxxii],[xxxiii]


ACS CAN’s Position on Smoke-free Laws

Exposure to SHS is an occupational hazard for many U.S. workers, including casino, restaurant, bar, and hotel employees, and a preventable cause of disease and premature death. ACS CAN advocates for the right of all people to breathe smoke-free air. No one should have to choose between their livelihood and their health.

ACS CAN urges state and local officials to pass and protect comprehensive smoke-free laws in all workplaces, including restaurants, bars and gaming facilities, to protect the health of all employees and patrons. These laws should include all forms of smoking, including but not limited to cigarettes, electronic cigarettes, cigars, hookah, pipes and cannabis. Policymakers should reject legislation that weakens smoke-free laws or removes authority from local governments to pass local smoke-free laws.


[i] U.S. Department of Health, Education, and Welfare. The Health Consequences of Smoking: A Report of the Surgeon General: 1971. Available at

[ii] U.S. Department of Health and Human Services (HHS). The Health Consequences of Involuntary Smoking: A Report of the Surgeon General. 1986. Available at

[iii] Pirkle JL, Flegal KM, Bernert JT, et al.  Exposure of the U.S. Population to Environmental Tobacco Smoke: The Third National Health and Nutrition Examination Survey, 1988 to 1991.  JAMA 1996;275(16): 1233-1240.

[iv] Gerlach KK, Shopland DR, Hartman AM, et al.  Workplace Smoking Policies in the United States: Results from a National Survey of more than 100,000 Workers.  Tobacco Control 1997; 6: 199-206.

[v] HHS. The Health Consequences of Involuntary Exposure to Tobacco Smoke: A Report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, Coordinating Center for Health Promotion, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2006. Available online at

[vi] HHS. How Tobacco Smoke Causes Disease: The Biology and Behavioral Basis for Smoking-Attributable Disease: A Report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2010.

[vii] Wortley PM, Caraballo RS, Pederson LL, et al.  Exposure to Secondhand Smoke in the Workplace: Serum Cotinine by Occupation.  Journal of Occupational and Environmental Medicine 2002; 44(6): 503-509.

[viii] Lawhorn NA, Lirette DK, Klink JL, et al. Workplace exposure to secondhand smoke among non-smoking hospitality employees.  Nicotine Tob Res 2013; 15(2):413-8.

[ix] Bohac DL, Hewett MJ, Kapphahn KI, et al. Change in Indoor Particle Levels After a Smoking Ban in Minnesota Bars and Restaurants. Am J Prev Med 2010; 39(6 Suppl 1):S3–9.

[x] Marin HA and Diaz-Toro EC. Reduced Exposure to Secondhand Smoke at Casinos in Puerto Rico After the Implementation of a Workplace Smoking Ban in 2007: A Pre-Post Design. Puerto Rico Health Science Journal 2011; 30(4):182–7.

[xi] Tsai J, Homa DM, Gentzke AS, Mahoney M, Sharapova SR, Sosnoff CS, et al. Exposure to secondhand smoke among nonsmokers—United States, 1988–2014. MMWR Morb Mortal Wkly Rep 67(48):1342–6. 2018.

[xii] Brody DJ, Faust E, Tsai J. Secondhand smoke exposure among nonsmoking adults: United States, 2015–2018. NCHS Data Brief, no 396. Hyattsville, MD: National Center for Health Statistics. 2021. DOI:

[xiii] Americans for Nonsmokers’ Rights (ANR). Summary of 100% Smokefree State Laws and Population Protected by 100% U.S. Smokefree Laws. April 1, 2024. Available at Accessed May 14, 2024.

[xiv] Ibid.

[xv] HHS. The Health Consequences of Smoking—50 Years of Progress: A report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Center for Diseases Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2014.

[xvi] Clark JD, Wilkinson JD, LeBlanc WG et al. Inflammatory markers and secondhand tobacco smoke exposure among U.S. workers. Am J Ind Med 2008; 51(8): 626-632.

[xvii] Arheart KL, Lee DJ, Dietz NA, et al. Declining Trends in Serum Cotinine Levels in U.S. Worker Groups: The Power of Policy. JOEM 2008; 50(1):57-53.

[xviii] HHS, 2014.

[xix] Travers MJ and Vogl L. Air Quality Effect of the Kansas Indoor Clean Air Law. Roswell Park Cancer Institute. January 2011. Available at Accessed June 6, 2011.

[xx] Shopland DR, Anderson CM, Burns DM, and Gerlach KK. Disparities in Smoke-Free Workplaces Among Food Service Workers. JOEM 2004; 46(4):347-356,

[xxi] Trout D, Decker J, Mueller C, et al.  Exposure of Casino Employees to Environmental Tobacco Smoke.  JOEM 1998; 40(3): 270-276.

[xxii] HHS, 2006.

[xxiii] Siegel M. Involuntary smoking in the restaurant workplace. A review of employee exposure and health

effects. JAMA 1993;270:490–493.

[xxiv] Palmersheim KA, et al. Madison Bartenders Baseline Survey: Preliminary Findings - Brief Report. Tobacco Surveillance & Evaluation Program, University of Wisconsin, Comprehensive Cancer Center, September 2005.

[xxv] Eisner MD, Smith AK, and Blanc PD. Bartenders’ Respiratory Health After Establishment of Smoke-Free Bars and Taverns.  JAMA 1998; 280(22): 1909-1914.

[xxvi] Wu, J., Yang, P., Wu, X., Yu, X., Zeng, F., & Wang, H. (2023). Association between secondhand smoke exposure and severe headaches or migraine in never‐smoking adults. Headache: The Journal of Head and Face Pain, 63(10), 1341-1350.

[xxvii] Babb S, et al. (2014). Secondhand smoke and smoking restrictions in casinos: a review of the evidence. Tob Control. Available online at

[xxviii] Flor, L. S., Anderson, J. A., Ahmad, N., Aravkin, A., Carr, S., Dai, X., ... & Gakidou, E. (2024). Health effects associated with exposure to secondhand smoke: a Burden of Proof study. Nature medicine, 1-19.

[xxix]  Repace JL, Jiang RT, Acevedo-Bolton V, Cheng KC, Klepeis NE, Ott WR, Hildemann LM. Fine particle air pollution and secondhand smoke exposures and risks inside 66 US casinos. Environ Res. 2011 May;111(4):473-84. doi: 10.1016/j.envres.2011.02.007. Epub 2011 Mar 25. PMID: 21440253.

[xxx] Ibid.

[xxxi] Tynan, M. A., Cohen, M. A., & Harris, J. R. (2023). What happens in Vegas, stays in your lungs: an assessment of fine particulate matter in casinos that prohibit and allow smoking in Las Vegas, Nevada, USA. Tobacco Control.

[xxxii] Guo J, Chai G, Song X, Hui X, Li Z, Feng X, Yang K. Long-term exposure to particulate matter on cardiovascular and respiratory diseases in low- and middle-income countries: A systematic review and meta-analysis. Front Public Health. 2023 Mar 28;11:1134341. doi: 10.3389/fpubh.2023.1134341. PMID: 37056647; PMCID: PMC10089304.

[xxxiii] Lim JU, Yoon HK. Narrative review: association between lung cancer development and ambient particulate matter in never-smokers. J Thorac Dis. 2022 Feb;14(2):553-563. doi: 10.21037/jtd-21-655. PMID: 35280473; PMCID: PMC8902116.